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1 Social Science & Medicine 57 (2003) Deliberations about deliberative methods: issues in the design and evaluation of public participation processes Julia Abelson a, *, Pierre-Gerlier Forest b, John Eyles a, Patricia Smith a, Elisabeth Martin b, Francois-Pierre Gauvin b a Centre for Health Economics and Policy Analysis, Health Sciences Centre, Rm 3H28, McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5, Canada b Groupe de recherche sur les interventions gouvernementales, Laval University, France Abstract A common thread weavingthrough the current public participation debate is the need for new approaches that emphasize two-way interaction between decision makers and the public as well as deliberation amongparticipants. Increasingly complex decision making processes require a more informed citizenry that has weighed the evidence on the issue, discussed and debated potential decision options and arrived at a mutually agreed upon decision or at least one by which all parties can abide. We explore the recent fascination with deliberative methods for public involvement first by examiningtheir origins within democratic theory, and then by focusingon the experiences with deliberative methods within the health sector. In doingso, we answer the followingquestions What are deliberative methods and why have they become so popular? What are their potential contributions to the health sector? We use this critical review of the literature as the basis for developing general principles that can be used to guide the design and evaluation of public involvement processes for the health-care sector in particular. r 2003 Elsevier Science Ltd. All rights reserved. Keywords: Public participation; Health-care decision making Introduction A convergence of activity among scholars and decision makers from a wide range of policy sectors appears to be takinghold of the public participation agenda. Where much previous attention has been given to normative discussions of the merits of, and conceptual frameworks for, public involvement, current activity seems largely focused on efforts to design more informed, effective and legitimate public participation processes with a strongevaluation component. Whether the decisions fall into the environmental, biotechnology or local government sphere, policy makers, regulators, experts and public advocacy groups agree on the importance of involvingthe citizenry in the decisions *Correspondingauthor. Tel.: , ext ; fax: address: (J. Abelson). that affect them but are grappling with how best to do this (Rowe & Frewer, 2000; Beierle & Konisky, 2000; Graham & Phillips, 1998; Pratchett, 1999; Simrell King, 1998; Leroux, Hirtle, & Fortin, 1998). This agreement has been reached from different underlyingmotivations those arisingfrom ideological (i.e., the desire to pursue democratic ideals of legitimacy, transparency and accountability) or more pragmatic (i.e., the desire to achieve popular support for potentially unpopular decisions) reasons (Rowe & Frewer, 2000; Abelson et al., 2002). Much of the current emphasis on participation methods is also a response to the prevailingview that methods used in the past are no longer appropriate for current decision making processes or for a more educated, sophisticated and less deferential public (Inglehart, 1995; Inglehart, Nevitte, & Basanez, 1996; O Hara, 1998). An additional motivation is the belief that more effective public participation techniques might foster, or even act as a substitute for, /03/$ - see front matter r 2003 Elsevier Science Ltd. All rights reserved. PII: S (02)00343-X

2 240 J. Abelson et al. / Social Science & Medicine 57 (2003) social capital, seen as necessary for improvinggovernance (broadly and in the health system) and manifested through collaborative problem solving among citizens in communities and organizations (Putnam, 1993; Veenstra & Lomas, 1999). Widespread calls for increased civic participation, capacity-buildingand the creation of social capital are the proposed antidote to the rise of individualism of the 1980s and view a re-created community as the cornerstone to improvements in social and economic conditions (Putnam, 1993; Sandel, 1996; Bellah, 1985). A common thread weavingthrough the current participation debate is the need for new approaches that emphasize two-way interaction between decision makers and the public as well as deliberation among participants. Increasingly complex decision making processes, it is argued, require a more informed citizenry that has weighed the evidence on the issue, discussed and debated potential decision options and arrived at a mutually agreed upon decision or at least one by which all parties can abide. An active, engaged citizen (rather than the passive recipient of information) is the prescription of the day. This current trend has emerged, in part, from the neo-liberal consumerist and customercentered public sector management philosophy that has dominated the 1980s and 1990s and from a governance philosophy that fosters reciprocal obligations between citizens and governments and emphasizes participation for collective rather than individual purposes (Graham & Phillips, 1998; Pratchett, 1999; O Hara, 1998). The creation of an appropriate public sphere (Habermas, 1984) for dialogue has become a recent pre-occupation in the health system recently as pressures mount for governments to clarify the relative roles of the private and public sectors in fundingand deliveringwhat have historically been largely public goods. The deliberative paradigm has gripped the health sector over the past decade with governments, research organizations and health authorities using deliberative methods to engage the public in values-based discussions about their health care systems (National Forum on Health, 1997; EKOS, 2000; CPRN, 2000; Wyman, Shulman, & Ham, 2000) and in priority settingprocesses to inform local health authority decision making (Lenaghan, New, & Mitchell, 1996; McIver, 1998; Coote & Lenaghan, 1997; Lenaghan, 1999; Cookson & Dolan, 1999; Dolan, Cookson, & Ferguson, 1999). We explore the recent fascination with deliberation methods by examiningtheir origins within the political theory and public participation literatures, and then focus more specifically on their use in the health sector. In doingso, we identify the potential contributions of deliberative methods to health systems decision making as well as the theoretical and methodological challenges faced in their utilization. To address these questions we discuss the strengths and weaknesses of more traditional methods such as surveys, public hearings and focus groups as well as the accumulated empirical literature on deliberative methods in the health sector. Finally, we use this critical review of the literature as the basis for the development and application of general principles that can be used to guide the design and evaluation of public involvement processes for the health sector in particular. Methods A systematic review of the participation literature was conducted to gather and assess the most seminal multidisciplinary works produced in recent years on two aspects of public participation: (i) empirical studies of public participation and consultation methods, practice and evaluation; (ii) theory and conceptual frameworks regarding the design and evaluation of public participation processes. All searches were conducted in a variety of article databases, 1 usinga set of predefined keywords. 2 Searches were limited to articles published in English and French since 1996 to update a database already established by one of the authors (JA) and to focus on 1 PsycINFO /08, Social Sciences Index 2/83-7/99, Wilson Business Abstracts 1/95-7/99, Sociological Abstracts /06, Humanities Index 2/84-7/99, General Sciences Index 5/84-7/99, PubMed , ABI/Inform (only articles that were available online were selected) 2 community participation and planning 37 hits, citizen participation and health 64 hits, public input and planning 2 hits, citizen participation and health care 24 hits, public participation and health care 21 hits, public involvement and local planning 1 hit, obstacles and citizen participation 6 hits, public input 16 hits, public involvement 16 hits, barriers and community participation 5 hits, barriers and citizen participation 7 hits, obstacles and community participation 4 hits, susan pickard 10 hits, citizen participation and local planning 7 hits, citizen participation and health and decision making 8 hits, community participation and local planning 3 hits, community participation and health education 19 hits, community participation and decision making 10 hits, public input and decision making 1 hit, citizen participation and health education 3 hits, public participation and health education 1 hit, citizen participation and planning 109 hits, public participation and health 51 hits, citizen participation 584 hits, citizen participation and health care and decision making 0 hits, public, participation 488 hits, public participation and health environ 0 hits, public participation and local planning 1 hit (already noted), barriers to citizen participation 0 hits, barriers and public participation 0 hits, community participation 219 hits, citizen engagement 0 hits, public involvement and health education 0 hits, public input and health and decision making 0 hits, public input and local planning 0 hits.

3 J. Abelson et al. / Social Science & Medicine 57 (2003) an accumulatingexperience with deliberative processes. Articles selected usingthe search strategy were supplemented by those recommended by colleagues or obtained from bibliographies. Research team members read and summarized the articles usinga standardized extraction sheet to elicit information about the context, use and evaluation of different methods. Democracy and deliberation The essence of democracy itself is now widely taken to be deliberation, as opposed to voting, interest aggregation, constitutional rights, or even selfgovernment. The deliberative turn represents a renewed concern with the authenticity of democracy: the degree to which democratic control is substantive rather than symbolic, and engaged by competent citizens. (Dryzek, 2000, p. 1) While a comprehensive review of the political theory of deliberation is beyond the scope of this paper 3 a basic understandingof the theoretical principles of deliberation helps to inform our review of the empirical literature in this area. Taylor s (1985) analysis of social theory as practice provides a useful backdrop for this discussion. Social theories (which include political theory) have the potential to do more than explain social life; they [also] define the understandings that underpin different forms of social practice and they help to orient us in the social world (Taylor, 1985, p. 108). In the context of deliberative methods, renewed interest in deliberative democratic theory has had a powerful influence over democratic practices such as public participation and consultation. What is deliberation? Deliberation refers either to a particular sort of discussion one that involves the careful and serious weighing of reasons for and against some proposition or to an interior process by which an individual weighs reasons for and against courses of action. (Fearon, 1998, p. 63) As implied in the above definition, in theory, deliberation can occur with others or as an individual process; it is the act of consideringdifferent points of view and comingto a reasoned decision that distinguishes deliberation from a generic group activity. To most deliberation theorists and practitioners, however, macro-level (group) deliberation has become the definingfeature of this participatory approach. Collective 3 For a more complete discussion of deliberative democratic theory see Dryzek (2000); Gutmann and Thompson (1996); Fishkin (1991;1995), Fishkin, Luskin, & Jowell, 2000; and Manin (1987). problem-solving discussion is viewed as the critical element of deliberation, to allow individuals with different backgrounds, interests and values to listen, understand, potentially persuade and ultimately come to more reasoned, informed and public-spirited decisions (Arendt, 1958; Habermas, 1984; Manin, 1987; Fearon, 1998; Fishkin, 1991; Gutmann & Thompson, 1996; Bostwick, 1999, 1996; Schudson, 1997; McLeod et al., 1999). As a social process, authentic deliberation relies on persuasion to induce participants reflection on and alteringof views (Dryzek, 2000; Przeworski, 1998; Cohen, 1989), in contrast to other communication approaches such as coercion, manipulation or deception which are achieved through ideological domination and interest group capture (Przeworski, 1998; Stokes, 1998). The presumption that power can be excluded from the deliberative dialogue and that status inequalities among participants can be reduced in pursuit of rational consensus around the common good has been challenged by a literature that emphasizes the centrality of power relations (Hindess, 1996; Elkin 1985; Bachrach & Baratz, 1962) and depictions of the public sphere of deliberative dialogue as an institutional mechanism for rationalizingpolitical domination by renderingstates accountable to (some of) the citizenry. (Fraser, 1997, p. 72). We recognize these challenges and reflect on them in our discussion of the development and application of design and evaluation principles for deliberative processes in the health sector. Over the past decade, the word deliberation has become ubiquitous amongpolitical philosophers, public opinion researchers, public policy analysts and communication scholars (Gastil, 2000). Although the benefits of incorporatingdeliberative elements into public policy decision-makingprocesses may be broadly accepted, there is theoretical debate about whether this deliberation is best undertaken within or outside government. The more traditional view is that it occurs within government (i.e., as a feature of representative democracy). But deliberation can also occur outside government as a mediated process through mass media communications. Alternatively, deliberation outside government could take the shape of direct citizen involvement in face-to-face meetings as the primary way to achieve the democratic ideal, a swingaway from representative, elite-driven politics to direct, citizendriven politics. Deliberation is more than merely a discussion of the issues. Emphasis is also given to the product that arises from discussion (e.g., a decision or set of recommendations), and the process through which that product comes about. Fearon (1998) considers the value of discussingissues before makinga decision to provide the opportunity to: (1) share views on a subject that voting does not allow (and associated activities such as the ability to communicate intensity of preferences and the

4 242 J. Abelson et al. / Social Science & Medicine 57 (2003) relative weights of preferences); (2) generate and consider a wider range of options or new alternatives that might not have been considered otherwise; (3) support or encourage more public-spirited proposals in contrast to those motivated by self-interest; (4) increase the legitimacy of the ultimate decision and to ease implementation or compliance with decision by giving everyone a say; and (5) improve the moral or intellectual qualities of the participants. While there is widespread support for the basic tenets of deliberation and its emphasis on improvingthe accountability, legitimacy and responsiveness of decision makingby buildingpopular involvement, these virtues conflict with other fundamental features of democratic participation such as political equality and representation. The size of cities and towns precludes full participation in the deliberative process as depicted by Aristotle in ancient Greece 4 or the American FoundingFathers in the New England Town Halls. The requirement to select a small group of representative participants subjects deliberative processes to critics who will dismiss their outcomes as unrepresentative (Gutmann & Thompson, 1996) while forcingthe architects of the deliberative exercise to carefully consider whom to involve. An additional double-edge built into the deliberative paradigm is the na.ıve assumption about the role of information as a tool for informingdialogue which ignores the reality of information as a source of power, with respect to its availability and use, in the participatory process. Deliberation and public participation processes Deliberative features have been incorporated into a broad grouping of methods that include citizens juries, planningcells, deliberative polling, consensus conferences and citizens panels. Individual methods may differ with respect to specific features such as participant selection (i.e., statistically representative vs. purposeful sampling); the number of participants (i.e., a hundred vs. a dozen); the type of input obtained or the number of meetings. Common to all, however, is the deliberative component where participants are provided with information about the issue beingconsidered, encouraged to discuss and challenge the information and consider each others views before makinga final decision or recommendation for action. In reviewingthese methods (and attemptingto categorize them as deliberative or not), we found that some methods such as citizens juries and their German equivalent (the planningcell) have deliberation as their definingfeature. Other methods such as citizens panels and deliberative polls, however, 4 Of course, the Athenians did not include the entire citizenry either, excludingslaves and women from their town halls. more closely resemble variants of traditional methods such as surveys and opinion polls. Citizens juries, panels and consensus conferences are routinely used to integrate technical information and values into planningand resource allocation decisions in the environmental, energy, education and local government fields. In these settings, their basic purpose has been to provide a forum for non-expert citizens, acting as value consultants, y to combine technical facts with public values into a set of conclusions and recommendations (Beierle, 1999). The menu of deliberative approaches has been described in detail elsewhere (Beierle, 1999; Webler, 1995; Pratchett, 1999; Leroux et al. (1998); O Hara, 1998). We offer a brief description of a selection of deliberative methods that have been used in the health sector. Citizens juries and planning cells have been run in the US and Germany respectively since the 1970s. The jury method was developed by Ned Crosby, who has promoted and/or organized juries at the state government level in agriculture, water and welfare policy; and at the national level for US health care reform, the federal budget and candidate ratings (Smith & Wales, 1999). Basic features of the method include the selection of participants to meet over several days as part of a single jury (i.e., one decision) (Crosby, 1995). Its German counterpart, the planning cell, has had more formal institutional support from government and agency sponsors who have commissioned the Research Institute for Citizen Participation to organize such cells to provide input to policy makingprocesses in the areas of local planning, national energy, technology and communication (Smith & Wales, 1999). In planning cells, deliberation takes place amongapproximately 25 randomly selected citizens who may meet several times. Results are presented to the sponsor, the media, and other interested groups. An accountability requirement is built into the process, which requires the sponsor to agree to consider the decisions produced by the planning cell (Coote & Lenaghan, 1997). Citizens panels are similar to juries in their composition and task but can have more permanency with the same, or a partially replaced group, meeting routinely to consider and make recommendations or decisions about different issues or on different aspects of a single decision-makingprocess. Consensus conferences, developed in Denmark, are used in a variety of settings and typically involve a group of citizens with varied backgrounds who meet to discuss issues of a scientific or technical nature. The conference has two stages: the first involves small group meetings with experts to discuss the issues and work towards consensus. The second stage assembles experts, media and the public where the conferences main observations and conclusions are presented. The consensus conference has been widely used in the field of medicine for

5 J. Abelson et al. / Social Science & Medicine 57 (2003) developing clinical guidelines, although lay participation is a feature of some conferences. Deliberative polling attempts to incorporate a deliberative process into the traditional opinion poll. Developed by James Fishkin in the early 1990s, the deliberative poll combines the strengths of a large representative, random sample while providingopportunities for discussion and deliberation over a 2 3 day period. The large scale and significant costs associated with runninga deliberative poll has resulted in its restricted application to national issues. Polls have been conducted on issues such as crime, the monarchy, the future of Europe and the UK s National Health Service and in association with presidential campaigns in the US Empirical studies of this method usingpre- and postdeliberation polls suggest that participant views do change as a result of the deliberative process although it is unclear precisely how this occurs (i.e., through several influential voices or through a fair and reasonable process). The outcomes produced from a deliberative poll are individual opinions (as with traditional polls) that are shaped by group deliberation (Fishkin, 1991, 1995; Fishkin, Luskin, & Jowell, 2000). Deliberation in the health sector Deliberative processes are a recent phenomenon in the health sector compared to a longer history of their use in other sectors. The National Health Service in the UK has been enthusiastic in its experimentation with deliberative methods since the early 1990s and NHS policy requiringa greater role for public views in setting health care priorities (Department of Health, 1992). The mail survey was the initial method of choice for eliciting patient, provider and public views with respect to perceived needs and priorities for health care resource allocation (Richardson, Charny, & Hanmer-Lloyd, 1992; Bowling, Jacobson, & Southgate, 1993; Heginbotham, 1993). Although a popular and conventional method for obtaining information from large groups of people about a range of subjects, surveys are limited in their ability to communicate, and obtain in-depth views about, complex issues. Interviewer-administered surveys achieved some success in addressingthese shortcomings but their limitations undoubtedly influenced the search for new public involvement methods (Donovan & Coast, 1996). Broader objectives of stimulatingdebate, improvingpublic understandingof complex health care issues, and the desire to achieve consensus around public and community values for health services priorities have provided a strongimpetus to introduce deliberative methods into the highly politicized world of health services priority setting. The citizens jury gained popularity in the UK and New Zealand in the mid-1990s as inputs to health care rationingand priority settingdecisions. Several juries have dealt with questions of whom should set priorities and how; others were asked to allocate resources within or between program areas (Lenaghan et al. (1996); McIver, 1998; Coote & Lenaghan, 1997; Lenaghan, 1999; Smith and Wales, 1999). Citizens panels have also been used by UK health authorities, although on a more limited basis, as a method for incorporatingcommunity values into local decision-makingprocesses (Bowie, Richardson, & Sykes, 1995). Deliberation-oriented focus groups have been used for obtaining the public views about health-care priority setting. In one health authority, a random sample of patients from two urban general practices was invited to attend two focus group meetings, two weeks apart, to assess the impact of the deliberative process on their views (Dolan et al. (1999); Cookson & Dolan, 1999). Although the NHS has been the principal laboratory for more recent experiments with deliberative processes, deliberative polling, citizens panels and public dialogue methods have been used elsewhere to involve citizens in a variety of national and local public involvement initiatives (Abelson, Lomas, Eyles, Birch, & Veenstra, 1995; Abelson, Eyles, Forest, McMullan, & Collins, 2001; CPRN, 2000; National Forum on Health, 1997). The seeds of the now more commonplace approaches to deliberation trace back to state and national priority settingexercises of the late 1980s and early 1990s in Oregon, Sweden, the Netherlands and New Zealand (Stronks, Strijbis, Wendte, & Gunning-Schepers, 1997; Coast, 1996; Cooper, 1995; Campbell, 1995; Honigsbaum, Calltorp, Ham, & Holmstrom, 1995). Evaluating deliberative methods Evaluation principles The approach taken to evaluation in most empirical studies of consultation or participation methods involves documentinghow a particular method was used, what results were obtained with at best, a short discussion of lessons learned or future recommendations appended to the study. This depiction also characterizes studies of deliberative processes in the health sector. Our review of empirical studies of deliberative methods in the health sector identified only one systematic attempt to evaluate a particular method the citizens jury usingpre-defined evaluation criteria (McIver, 1998). While a useful set of practical recommendations for employingdifferent deliberative methods is beginning to emerge from these experiences, there is a paucity of rigorous studies of these approaches to determine their efficacy. Attempts to address this gap have been initiated by participation scholars in the environmental policy field (which has had a long and rich history of public participation) through the

6 244 J. Abelson et al. / Social Science & Medicine 57 (2003) development of comprehensive frameworks to evaluate public participation processes generally and deliberative approaches more specifically. The most comprehensive attempt to develop an evaluation framework is based on a normative theory of public participation (based on a revision of Habermas concepts of ideal speech and communicative competence 5 ) (Renn, 1992; Webler, 1995) which identifies two key meta-principles: fairness and competence, against which deliberative participation processes can be judged (Webler, 1995). The fairness goal requires the equal distribution of opportunities to act meaningfully in all aspects of the participation process including agenda setting, establishing procedural rules, selectingthe information and expertise to inform the process and assessingthe validity of claims. The competence goal deals more with the content of the process. A competent process ensures that appropriate knowledge and understanding of the issue is achieved through access to information and the interpretation of the information. Competence also requires that appropriate procedures be used to select the knowledge that will be considered in the process. As discussed at the outset of the paper, approaches to the design and, subsequently, to the evaluation of deliberative methods have occurred within a narrow theoretical frame (i.e., a process that ensures equality of access, procedural fairness and mutual respect will produce legitimate outcomes) that ignores, or at least tries to neutralize, the role of power within political institutions and the role of political institutions as purpose- or end-creatingactivities (not merely the means for producinga particular set of outcomes (Elkin, 1985, p. 262). We recognize the challenges to this theoretical frame and discuss them in the following sections. The Renn and Webler framework, however, has been a major influence through the widespread use and adaptation of the fairness and competence principles in numerous evaluation studies, includingthose in the health sector (Petts, 2001; Rowe & Frewer, 2000; Pratchett, 1999; Beierle, 1999; Beierle & Cayford, 2000; McIver, 1998; Smith & Wales, 1996; Crosby, 1995). As such, we have chosen to draw on this now familiar work for its basic elements (rather than its theoretical frame) and later work of Beierle (1999) to identify the four key components of any evaluation of a deliberative process: (1) representation; (2) the structure of the process or procedures; (3) the information used in the process; and (4) the outcomes and decisions arisingfrom the process. Table 1 considers these components and the specific 5 We note the formative influence that Hannah Arendt s work has had on Habermas communicative reasoningtheory through her thinking about the development of citizen capacities for free expression, reasoned judgement and political action through appropriate institutional mechanisms. See The Human Condition (1958) and On Revolution (Arendt 1962). evaluation criteria subsumed within each. Renn and Webler s fairness and competence criteria are captured within the first three columns while the emphasis on outcome, from Beierle s work, has been captured in the fourth. Each of the table elements is briefly discussed below. Representation: All evaluation frameworks include some criteria about how representation issues might be assessed and emphasize the extent to which different types of representation can be achieved (e.g, geographic, demographic or political). Consultation processes may also be assessed against criteria that emphasize both access to a consultation (by providingequal opportunities) as well as clarity and legitimacy in the selection process. Procedures: Assessingthe extent to which the procedural aspects of a consultation process are legitimate, reasonable, responsive and fair are fundamental aspects of the evaluation process (Pratchett, 1999; Smith & Wales, 1999; Crosby, 1996). Legitimacy and responsiveness principles are assessed by consideringquestions such as: (1) What point in the decisionmakingprocess is public input beingsought (i.e., is the public involved in significant aspects of decision-making such as agenda setting or in minor decisions only?); (2) At what level of the organization does the participation occur? (i.e., who is listeningand ultimately responding to the public?). Evaluations of deliberative processes in particular would also assess elements of the process such as: (1) Was ample time provided for discussion? (2) Did participants have the opportunity to challenge the information presented? (3) Was mutual respect and concern for others emphasized throughout deliberations? Information: Decisions regarding what and how information is selected, presented and interpreted are crucial elements of any consultation process and are therefore important evaluation principles to consider. Table 1 describes each of these components and also suggests a fourth category related to the quality of input obtained which emphasizes the information received by rather than provided to participants. Outcomes: The final set of evaluation principles considers the various set of potential outcomes of the public participation process. These may include, first, legitimacy and accountability, in the context of decision makingitself rather than the process leadingto the decision. Elements to consider include an assessment of the extent to which public input was incorporated into the final decisions, how decisions and the public s input into these decisions were communicated to the public, and the degree to which the decision-making authority was found to respond to the public s input (i.e., what aspects of the input did they incorporate or not incorporate and why?). Secondly, participants must be satisfied with the process which must lead to a more

7 J. Abelson et al. / Social Science & Medicine 57 (2003) Table 1 Principles for the Design and evaluation of public participation processes Representation Procedural rules Information Outcomes/decisions Legitimacy and fairness of selection process Is there a representative sample? Degree of citizen control/input into Characteristics Legitimacy and accountability of: agenda setting, establishing rules, selectingexperts, information Accessibility Decision-making Readability Communication of decisions Digestibility Responses to decision or input Deliberation Selection and presentation More informed citizenry Geographic Amount of time Who chooses the information Demographic Emphasis on challenging experts, Who chooses the experts information Political Mutual respect Community Participant selection vs. Self-selection Inclusiveness (broad) vs. Exclusiveness (narrow) Credibility/legitimacy of process Interpretation Achievement of consensus over the decision What point in the decision-making Adequacy of time provided to (I.e., Broad-based understanding process is input beingsought? consider, discuss and and acceptance of final decision) challenge the information Who is listening? (e.g., Influential Better (or different) decisions decision-makers or junior staff) informed citizenry with a better understandingof the issue. Thirdly, an important outcome is the extent to which consensus was achieved and finally, it must be asked if better decisions were taken and the participation process improved policy making(i.e., did the process make a difference to the final decision?). How well do deliberative methods fare in the health sector? Applyingthese principles to our discussion of deliberative methods highlights the numerous and potentially competinggoals for public participation processes and, consequently, the trade-offs inherent in designing public participation processes that, in emphasizinga particular goal, may sacrifice another. For example, emphasis on the design of procedurally fair and legitimate processes that provide opportunities for meaningful involvement, shared learning and the consideration of a range of views the pillars of deliberative methods are, by design, exclusive processes that involve only a small group of citizens. Furthermore, the outcomes (i.e., decisions) may not be held accountable to or by the broader community. The small number of citizens who can meaningfully deliberate at any one time is clearly a weakness of deliberative methods such as citizens juries that involve fewer than 20 individuals in the process. Underlyingthis concern are issues of participant selection (given the amount of time required to participate and whether paid or volunteer) and representation (i.e., can such a small group of participants ever adequately represent the range of views at a local community, regional or national level?) (Coote & Lenaghan, 1997; McIver, 1998; Dunkerley & Glasner, 1998). Larger, multiple group processes with adequate attention given to fair participant selection processes may overcome these criticisms (McIver, 1998). As well, features of more traditional citizens survey panels have the potential to address the representation problems although individual level interior deliberation obviously sacrifices the goal of group discussion. Citizens juries and group panels clearly offer great potential for meetingmany of the procedural rules principles. Their very structure emphasizes group deliberation through a process of acquiring and consideringinformation for the purposes of reaching some considered judgment on an issue. Citizens jury experiences in the UK have provided these forums for exchange with participants coming away believing they ve learned a great deal from the process (i.e., creatinga more informed citizenry). Indeed, many consider their participation in the group discussions to be the most valuable part of the experience (Fishkin, 1995). In general, jurors tended to praise the fact that the models enabled them to meet new people from

8 246 J. Abelson et al. / Social Science & Medicine 57 (2003) different backgrounds and perspectives, to learn about a new area, to participate in decision making, and to foster a sense of community (Lenaghan, 1999, p. 54). Yet few evaluations have assessed what jury sponsors have learned from the process, implyingthat the information flow and learningis uni-directional (i.e., from decision-maker to participant) rather than a twoway information exchange as idealized by the principles of the deliberative forum. Assessingprocedural fairness is no simple matter in the health sector, for a variety of reasons, many of which relate to what information is presented, how and by whom (column 3). The selection and role of witnesses in the jury process has come under scrutiny in the citizens jury process. For jury issues that have a heavy scientific orientation, witnesses play a crucial role in the presentation and communication of technical information. Although expert medical and/or scientific witnesses play an obvious role, lay witnesses can also be helpful in improvingthe public s understandingof complex principles but only, as one lay witness describes, if they are to be used on an equal footingwith professionals, with equal time and equal opportunity for questioning, y (Dunkerley & Glasner, 1998, p. 188). As with the juror selection process, consideration also needs to be given to the representativeness of witnesses (Dunkerley & Glasner, 1998). Precisely how this is done is less clear as there appear to be no pre-defined roles and responsibilities for jurors or jury organizers. Implied in its name is the notion that the citizens jury somehow mirrors its legal counterpart. When comparing the two, however, the citizens jury and its associated activities only partially reflect the elements of a legal jury. If we consider the actors and roles in a legal jury we would include judge, jury, lawyers, witnesses and clients and the interactions between them. The citizens jury that has been implemented in the health sector, however, appears to involve (at least explicitly) merely a jury and witnesses. This raises the issue of how the jury interacts with witnesses in the absence of lawyers who play key roles in witness selection, preparation, questioningand cross-examination. While some of the juries described in the literature identify roles for moderators and sponsors, their roles and accountabilities are much less clearly defined than are those in the legal system, thus raising questions about the authenticity of the jury process and the heavy burden placed on the citizen to act as judge, lawyer and jury. Despite the great potential the jury offers for meaningful public involvement, the tight hold that decision makers and/or sponsors typically have on its design can undermine its legitimacy. Participant evaluations of deliberative processes have also raised concerns about the amount of information presented and the speed with which participants were asked to digest and interpret it (Coote & Lenaghan, 1997; McIver, 1998; Lenaghan, 1999). An additional concern is the public s ability to judge the adequacy and quality of the information presented which places them at risk of beingeasily influenced or undermined (either intentionally or unintentionally) by jury sponsors, organizers or even witnesses. As discussed in the evaluation of a Welsh citizens jury held in 1997, sponsored by the pharmaceutical company Smith, Kline and Beecham, the motives of the sponsors may have been at odds with the democratizingphilosophy underpinningthe citizens jury concept (Dunkerley & Glasner, p. 187). This is not just a problem for citizens juries, of course, but one for all deliberative methods because of their perceived strength in contributing to an informed public; a reasonable question to ask then is informed by whom and what? Even with significant lay involvement in and control over the selection of experts and information, the vast majority of the public will defer to the experts when it comes to these decisions because they may not have the expertise required to critically appraise the information presented. At the root of this lies the unavoidable power imbalance between those who possess what seems to be the desired information, who control its dissemination and the forum within which it is debated (the sponsor of the deliberative process), and those who do not (the participants). Power imbalances may also exist among the participants themselves which may be masked by institutionalized comfort amongparticipants, apparently takingpart equally. This comfort is neither realistic nor worth pursuingas it masks inequalities that exist amongparticipants and between participants and decision makers. The institutionalized mechanism of the deliberative process also seeks to minimize, at least implicitly, potentially productive conflict amongparticipants that can enrich the deliberative process (see Fraser, 1997) and the role that community dynamics, culture and shared histories play in influencinga deliberative process. A further dilemma posed by the introduction of a deliberative democracy agenda within the health sector (as well as other public policy sectors) is that once exposed to the complexities of the system, participants become sympathetic to the challenges faced by decision makers who deal with these types of issues on a daily basis. Public participant experiences with deliberative processes routinely reflect on this point by acknowledging the difficult yet stimulating work they were being asked to do and through changed opinions about their desired decision-makingrole before and after becoming more informed about the complexities of health sector decision making(abelson et al., 1995). There is the additional threat that as citizens become more informed about the health care system and are exposed to the harsh realities of makingdifficult and highly politicised

9 J. Abelson et al. / Social Science & Medicine 57 (2003) health care decisions, they may lose their lay perspective and their views may become more closely aligned with those of the professionals (Mullen, 2000). A balance appears to be required between the development of an informed, engaged citizenry who can actively and effectively contribute to decision-makingprocesses but who do not become co-opted (either formally or informally) by that process. 6 Ultimately, the effectiveness of any public participation or consultation process should be judged by some measure of the outcomes achieved. Agreement on what constitutes desirable or appropriate outcomes has been a major point of debate within the public participation literature typically pittingthose concerned more with process measures against those more interested in what difference the process makes to the final decision(s) taken. For their part, public participants are demanding greater accountability for their participation. At minimum, they want the resultingdecision communicated to the public with some demonstration of how the public s input was used or considered in the decision-making process (Litva et al., 2002; Abelson et al., 2002). Here, once again, deliberative processes appear to offer more promise than reality. The limited experiences with deliberative methods in the health sector, to date, have demonstrated that the outcomes of deliberations are rarely, if ever, bindingand are often heavily managed by the sponsoringorganization, typically the health authority. Evaluations of deliberative processes in the health sector have identified concerns amongpublic participants about what, if anything, would be done with their recommendations (Coote & Lenaghan, 1997; McIver, 1998; Lenaghan, 1999; Dunkerley & Glasner, 1998). While, in theory, deliberative processes could be designed to guarantee binding decisions, in reality, the stakes are often too high to delegate this authority to a group of citizens and the public may not care to assume this level of decision-makingauthority (Abelson et al., 1995; Litva et al., 2002). Opportunities and challenges for deliberative methods in the health sector With so few examples of deliberation in the health sector and the lack of rigorous evaluation, it is difficult to assess the normative claims that are made about 6 See Selznick (1953) for an in-depth analysis of the sociological concept of co-optation in his landmark study of the Tennessee Valley Authority. He defines co-optation as the process of absorbingnew elements into the leadership or policydeterminingstructure of an organization as a means of averting threats to its stability or existence. Although this definition does not explicitly address the issue of co-optation through deliberative democratic processes, it identifies the relevant issue of usinga democratic process for pragmatic purposes. deliberation. We offer a set of guiding principles that can be used to assess the extent to which deliberative methods have achieved, and can potentially achieve, some of the oft-cited objectives for public participation processes. Through this process, we have identified various trade-offs in the pursuit of one objective over another, some potential threats to the pursuit of legitimate deliberation and some options for mitigating these threats. When to deliberate For those seekingto determine the most optimal conditions under which deliberative methods might be used, the empirical literature, once again, offers mixed reviews. For example, the substantial costs associated with deliberative methods such as citizens juries appear to justify their use only for substantive issues where there are clearly articulated options and for which there is available information (McIver, 1998). By creatingthis type of open, transparent process, however, the jury becomes vulnerable to interest group capture, particularly where clear and identifiable recommendations are produced that are obvious targets for mobilization. For issues that are particularly thorny, such as many health care priority settingdecisions, the mere prospect of a jury beingheld and the process of juror recruitment can precipitate interest group mobilization. These threats have led others to recommend the use of deliberative processes, such as citizens panels, early on in a decision-makingprocess before stakeholder views become entrenched (Kathlene & Martin, 1991). The type of issue and decision-makingcontext are clearly important considerations in the choice and design of deliberative process. Juries may be more amenable to processes that emphasize a decision amongoptions while citizens panels and deliberative pollingmay be more appropriate for elicitingpublic values. A concern relevant to the health sector is that deliberative processes are difficult to execute and, therefore, should not be used to inform difficult decisions (e.g., choosing between programs, limiting program eligibility criteria or closing facilities) or around crisis issues when opportunities for considered judgment may be reduced. The extent to which crisis rhetoric is used by interest groups operating in the health sector may, once again, thwart efforts to effectively engage in deliberative processes. Alternatively, that may be precisely when deliberation is most important, when difficult, values-based choices need to be made (O Hara, 1998). Cynics would argue that this is precisely why there has been so much interest in experimentingwith deliberative processes in the health sector. It allows decision makers to diffuse or at least share the blame for these difficult decisions with a participatingpublic.

10 248 J. Abelson et al. / Social Science & Medicine 57 (2003) Public willingness to deliberate Increased citizen engagement through deliberative processes is viewed as a direct response to public discontent with past public participation experiences, and their loss of deference to, and trust in, public officials (O Hara, 1998; Maxwell, 2001; Nevitte, 1996; Graham & Phillips, 1998). What evidence do we have from the public that they welcome this increased role and commitment to a new style of participation? Public opinion polls indicate that citizens are lookingfor different ways of participating(ekos, 2000). Experiences with public involvement in deliberative exercises such as citizens juries and panels have generated positive feedback from participants who welcome the opportunity to become more informed about their local health system but who also express concerns about the outcome of the process given the substantial time investment. Participants in these types of deliberative processes also tend to emerge from these experiences with a fuller understandingof the complexities of decision makingin the health sector and, hence, renewed respect for existingdecision makers (McIver, 1998; Coote & Lenaghan, 1997; Abelson et al., 1995). Recent evidence suggests, however, that the public may not be that willingto participate in time consuming, face-toface processes, especially if they cannot be assured that their involvement will make a difference (Abelson, Eyles, Forest, McMullan, & Collins, 2001). But we know that citizens are more likely to get involved when their interests are affected, typically when they are afraid of losingsomethinglike their local hospital or if they or a close one suffers from a particular health problem (Abelson, 2001; Henig, 1982; Kraft & Clary, 1991; Parry, Moyser, & Day, 1992). For participation in more routine health-care decision making, organizations tend to rely on a small group of interested individuals who have a clear stake in the outcome of the decision-makingprocess or who can be convinced of the need for them to step forward to promote the public interests of their community (Abelson, 2001). If deliberative methods are to succeed, there needs to be buy-in at the community level, especially by civic leaders, to mobilize citizen deliberation. Despite its potential, the challenges of engaging the public in deliberation in the health sector are numerous. These challenges include: 1. How to mitigate strong vested interests which may try to use the deliberative process to sway the discussion or, ultimately, the outcome of the exercise 2. How to mitigate potential biases introduced in witness and information selection and presentations due to the lack of citizen control/ownership of the deliberative process 3. How to achieve representativeness when citizens do not want to participate 4. How to ensure accountability to the participants for the outcome of the deliberation when the deliberative process is only one input into the decision-making process or if the final decision is several years into the future or may not be taken at all. 5. How to build an infrastructure of civic deliberation within communities and public institutions. Future research The theoretical literature routinely compares and contrasts public participation methods to illustrate their similarities and differences and to offer guidance about which methods should be used given a particular decision-makingcontext. The empirical studies reviewed here suggest that some methods may be preferable to others dependingon the goals for participation. Further, there are particular challenges faced by deliberative methods as they have been used in the health sector. Our review of these studies has failed to identify a single study in the health sector, or elsewhere, that has rigorously compared the use of different participation methods (e.g., comparison of different deliberative methods or comparison of one deliberative method vs. a non-deliberative method method) for the same decision-makingprocess, or assessed the relative costs of these methods against their effectiveness. 7 There are significant challenges to undertaking this type of research. First, the comparison of public participation processes is complicated by the different contexts within which participation is undertaken and expressed. Second, disentangling the effects of participation from other effects is also very complicated makingit difficult to determine the outcomes upon which to assess the process (Zakus & Lysack, 1998). For example, a citizens jury implemented in one community to address one set of issues is not easily replicated in another community for the same set of issues, raisingserious challenges to conductingcross-jurisdictional comparative evaluations of public participation processes. Within a specific decision-makingprocess and context, however, similar approaches may be compared such as different survey techniques or different deliberative methods. Moreover, for some issues such as priority settingdecisions, it may be reasonable to consider such diverse methods as juries and surveys to compare the views of an informed vs. 7 We identified one pilot study evaluated three citizen participation approaches mail surveys, community conversations and community dinners against three pre-determined criteria: (i) whether participants were demographically representative of their community; (ii) whether the methods focused on communal vs. individual-specific issues; and (iii) whether the processes elicit information about underlyingbeliefs and values regarding the issue under study (Carr & Halvorsen, 2001). Although formal evaluation criteria were used in this evaluation, the findings are considered preliminary and not widely generalizable.

11 J. Abelson et al. / Social Science & Medicine 57 (2003) uninformed group of citizens. A strong case can be made for this type of comparative research given citizen concerns about achieving value for money, their desire for accountable consultation (Litva et al., 2002) and decision-makers interest in low-cost highyield consultations that do not divert significant resources away from service delivery. Learningmore about what the public wants and expects from public consultation and participation processes will be an important input into this research agenda. Conclusions Our review is intended to provide health researchers and decision makers with the theoretical underpinnings of deliberative methods and insights into their recent popularity in the health sector. The examination of their application to the health sector provides some practical guidance for decision makers. The paucity of rigorous evaluations is, however, of concern for those lookingto draw generalizable lessons to inform the design of more effective participation processes in the future. Indeed, more work is needed to unpack the meaningof effectiveness in the context of public participation methods and to systematically assess various methods against pre-determined evaluation criteria. Some of this work has begun in the fields of science, technology and environmental policy (Rowe & Frewer, 2000; Beierle & Cayford, 2002; Petts, 2001). Researchers and decision makers in the health sector can contribute to this knowledge base by undertaking more rigorous evaluations of public participation approaches usingclearly defined and agreed upon criteria. In the meantime, several key messages arise from the literature so far, to suggest that clear thinking about why you want to consult, with whom and about what will take participation practitioners at least part of the way. Deliberative approaches offer much promise for achievingthe goals of more effective, informed and meaningful participation. As their theoretical underpinnings suggest, they also have the potential to foster a more engaged, publicspirited citizenry and early experiments with these processes suggest that the public finds these processes stimulatingand informative. Whether deliberative processes lead to improved or even different decisions is not yet known. Their future promise, however, lies in the ability for those constructingthem to overcome numerous challenges to their legitimacy driven by an increasingly demanding and discerning public. References Abelson, J. (2001). Understandingthe role of contextual influences on local health-care decision making: Case study results from Ontario, Canada. Social Science Medicine, 53, Abelson, J., Eyles, J, Forest, P.-G., McMullan, C., & Collins, P. (2001). Final Report of the Brant County Health Goals Project: A Citizens Panel Study. Abelson, J., Forest, P-G., Eyles, J., Smith, P., Martin, E., & Gauvin, F-P. (2002). Obtainingpublic input for health systems decisionmaking: Past experiences and future prospects. Canadian Public Administration, 45(1), Abelson, J., Lomas, J., Eyles, J., Birch, S., & Veenstra, G. (1995). Does the community want devolved authority? Canadian Medical Association Journal, 153, Arendt, H. (1958). The human condition. Chicago: University of Chicago Press. Arendt, H. (1962). On revolution. New York: Penguin. Bachrach, P., & Baratz, M. (1962). Two faces of power. American Political Science Review, 57(4), Beierle, T. C. (1999). Usingsocial goals to evaluate public participation in environmental decisions. Policy Studies Review, 16(3 4), Beierle, T. C., & Cayford, J. (2002). Democracy in practice: Public participation in environmental decisions. Washington, D.C: Resources for the Future. Beierle, T., & Konisky, P. (2000). Values, Conflict and Trust in Participatory Environmental Planning. Journal of Policy Analysis and Management, 19(4), Bellah, R. (1985). Habits of the heart: Individualism and commitment in American life. Berkeley: University of California Press. Bostwick, M. (1999). Twelve Angry Citizens: Can citizens juries improve local democracy in new zealand? Political Science, 50(2), Bowie, C., Richardson, A., & Sykes, W. (1995). Consultingthe public about health service priorities. British Medical Journal, 311, Bowling, A., Jacobson, B., & Southgate, L. (1993). Explorations in Consultation of the Public and Health Professionals on Priority Settingin an Inner London Health District. Social Science and Medicine, 37(7), Canadian Policy Research Networks (2000). Canadians speak out on health care. The Society We Want Newsletter 5, 1 7. Carr, D. S., & Halvorsen, K. (2001). An Evaluation of Three Democratic, Community-Based Approaches to Citizen Participation: Surveys, conversations with community groups, and community dinners. Society and Natural Resources, 14, Campbell, A. V. (1995). Definingcore health services: The New Zealand experience. Bioethics, 9, Coast, J. (1996). Core services: pluralistic bargaining in New Zealand. In J. Coast, J. Donovank, & S. Frankel (Eds.), Priority setting: The health care debate (pp ). Chichester: Wiley. Cohen, J. (1989). Deliberation and democratic legitimacy. In A. Hamlin, & P. Pettit (Eds.), The good polity: normative analysis of the state (pp ). Oxford: Basil Blackwell. Cookson, R., & Dolan, P. (1999). Public views on health care rationing: A group discussion study. Health Policy, 49(1 2), Cooper, M. H. (1995). Core services and the New Zealand health reforms. British Medical Bulletin, 51(4),

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